A qualitative assessment of barriers and facilitators of telemedicine volunteerism during the COVID-19 pandemic in India

Background The COVID-19 pandemic further propelled the recent growth of telemedicine in low-resource countries, with new models of telemedicine emerging, including volunteer-based telemedicine networks. By leveraging existing infrastructure and resources to allocate health personnel more efficiently, these volunteer networks eased some of the pandemic burden placed on health systems. However, there is insufficient understanding of volunteer-based telemedicine models, especially on the human resources engagement on such networks. This study aims to understand the motivations and barriers to health practitioner engagement on a volunteer telemedicine network during COVID-19, and the mechanisms that can potentially sustain volunteer engagement to address healthcare demands beyond the pandemic. Methods In-depth qualitative interviews were conducted with health practitioners volunteering on an Indian, multi-state telemedicine network during the COVID-19 pandemic. Data were analyzed using thematic content analysis methods. Results Most practitioners reported being motivated to volunteer by a sense of duty to serve during the pandemic. Practitioners suggested organizational-level measures to make the process more efficient and facilitate a more rewarding provider–patient interaction. These included screening calls, gathering patient information prior to consultations, and allowing for follow-up calls with patients to close the loop on consultations. Many practitioners stated that non-financial incentives are enough to maintain volunteer engagement. However, practitioners expressed mixed feelings about financial incentives. Some stated that financial incentives are needed to maintain long-term provider engagement, while others stated that financial incentives would devalue the volunteer experience. Most practitioners highlighted that telemedicine could increase access to healthcare, especially to the rural and underserved, even after the pandemic. Practitioners also expressed an interest in continuing to volunteer with the network if the need arose again. Conclusion Our study findings suggest that practitioners are highly intrinsically motivated to volunteer during large healthcare emergencies and beyond to address the healthcare needs of the underserved. Following the recommendations presented in the study, telemedicine networks can more successfully engage and maintain volunteer practitioners. Volunteer-based telemedicine networks have the potential to bridge shortages of health personnel in resource-constrained settings both in times of crises and beyond.


Background
Telemedicine, where medical services are provided using modern technology tools such as voice over internet, telephone, and other videoconferencing methods, covers a range of healthcare specializations and domains [1].From its traditional application in urgent care, the scope of telemedicine applications has expanded to provide more routine and chronic care, including psychiatry, radiology, and post-partum care [2,3].Telemedicine has also been found to address persistent health system challenges, including high patient demand and high costs [4,5], and increase access to care for rural areas, underserved populations and in international development [6,7].
The growth of telemedicine has been particularly acute in low-and-middle-income countries (LMICs), driven by investments in information and communications technology infrastructure, exponentially growing healthcare markets [8,9], and the potential to expand access to care [10].For example, in Brazil, state governments established small-scale telemedicine networks connecting public teaching hospitals with municipal health departments to reach vulnerable populations [11].In India, a 2019 report estimated that replacing 30-40% of consultations by telemedicine could save the country up to $10 billion and improve care for the poor and underserved [12].
The pandemic exponentially increased telemedicine's growth [13], expanding access to care while allowing for new channels of healthcare delivery [14].Several countries saw new platforms emerge and existing telemedicine platforms reported drastically increased usage, often driven by government support [15,16].Telemedicine was shown to be feasible, acceptable, and effective in improving health care outcomes [17].In LMICs characterized by shortages of health personnel [18] and infrastructure [19,20], telemedicine enabled a more efficient allocation of medical resources.By building on existing technologies and resources, telemedicine circumvented shortages of health practitioners and increased access to healthcare services [21][22][23].A new model of telemedicine that leveraged medical volunteers emerged.
Existing literature on volunteerism primarily focuses on physicians during non-public health emergencies, leaving much to understand on how online volunteerism may be leveraged to increase access to healthcare both during emergencies and during regular times.Studies have found that despite altruistic motivation, age, interest, opportunity cost of engagement, and lack of psychological support pose as barriers to sustained volunteerism [24][25][26].Technology literacy and costs of learning and platform familiarization are the identified barriers to volunteering through telemedicine [27].However, the link between online volunteerism and telemedicine is less studied, especially domestic telemedicine volunteerism.
In this study, we interview volunteer health practitioners of StepOne, an Indian, audio-only telemedicine network.StepOne is a COVID-induced private citizens' collective that brings together citizens, health practitioners, and technology startups to augment the Indian healthcare delivery infrastructure to manage COVID- 19.StepOne is unique because (1) it is completely volunteer-driven, making it a highly cost-effective model; (2) it partners with state and local governments to efficiently leverage the existing health system infrastructure; and (3) its algorithm matches health practitioners and patients on language and region to facilitate community and capitalize on familiarity with the local health system.The public-private partnership model to address a large public health crisis is especially important in India where an estimated 812 million people who live on less than $3/day (60% of the population) [28] depend on the severely underfunded public healthcare system [29].Between January and July 2021, Ste-pOne handled 31 million active cases of COVID-19 in India.During the disastrous second wave of COVID-19, the flexibility of the StepOne model enabled a 500% increase in the number of active medical volunteers from 2000 in April 2021 to 12,000 in May 2021.
This study examines the individual and contextual barriers and facilitators to participation in telemedicine faced by health practitioners.We ask providers on Ste-pOne about their views on telemedicine, on incentives as motivators, the future of telemedicine, their motivation for volunteering, and the barriers that inhibit engagement.The study results are applicable to other low-resource settings to improve the effectiveness and sustainability of volunteer telemedicine programs and extend access to health care both during and outside of large-scale public health emergencies.

Research questions
The study addresses the following questions: (1) What are the motivations for and barriers to provider engagement with a volunteer telemedicine program during the COVID-19 pandemic?(2) What is the value of financial and non-financial incentives in motivating volunteer provider engagement in telemedicine?((3) What are the advantages and disadvantages of providing telemedicine consultation versus in-person consultation?4) How will the COVID-19 pandemic affect future volunteer telemedicine programs?

Recruitment
Survey participants were recruited using convenience sampling.The StepOne team shared an email-based recruitment survey with all their health practitioners.The survey captured demographic details, including respondent age, experience, and geography.A total of 39 responses were received, and 18 interviews were conducted based on respondent availability.

Study design and data
Fifteen semi-structured interviews and one focus group interview with three participants were conducted, and recorded with consent, via Zoom between October 2021 and December 2021.Prior to the interviews, the questionnaires were pilot-tested through mock interviews within the research team's members.
The recruitment form data was anonymized before being used by the interviewers, and each interview was coded to protect the anonymity of the respondent.The collected data were analyzed using the software Atlas.tiCloud.Throughout the process, there was no de-anonymization.

Demographic characteristics
Interviewees comprised 14 health practitioners, including dentists and homeopaths, and four medical students.Medical students are limited in the scope of medical services they can provide and their ability to prescribe drugs, homeopathy is an alternative medicine, and dental services differ from physician-prescribed medical services.Table 1 shows the characteristics of the participants.This sample size of 18 participants allowed for content saturation as no new codes or themes emerged after 14 interviews.The themes identified from the focus groups corresponded to the results from the semi-structured interviews and complemented the interview results.

Analysis
Three members of the research team coded the interviews.To ensure consistency among coders, the team first collectively built the code book and jointly coded one transcript, resolving any discrepancies until consensus was reached.The remaining transcripts were then coded individually, with questionable quotes and codes discussed.Coding was conducted by reading each transcript, assigning predetermined codes to packets of text, and creating new codes and axial themes that reflected important information related to the research questions.The interviews were analyzed with a deductive and thematic content approach, where the research questions provided a framework for the analysis as well as to create categories to organize the coded text.The direct quotes were organized in a matrix display in excel, organized by category and participant.The matrix display visually represented the range of responses to each research question and subsequent theme.Three research team members individually analyzed the information in the matrix to draw conclusions, note patterns, themes, contrasts, and comparisons.Following this, the team discussed their conclusions and key quotes, collaboratively selecting the most informative, helpful, and representative quotes for each research question and theme.Appendix 1 contains the entire list of quotes.The results of the qualitative analysis are presented below, organized by research question.

Motivations and barriers to engaging with a volunteer telemedicine program during COVID-19 Motivations
An innate sense of duty to help as doctors during the pandemic, including the ability to serve patients in farto-reach areas motivated many providers to volunteer on StepOne by.One volunteer stated: "It is a social service.I feel it is our duty (to provide our services during the lockdown)".[Subject #1].Some practitioners stated that trainings conducted by specialists and experts on StepOne provided them with authenticated information on COVID.For practitioners such as dentists, volunteering on StepOne allowed them to do something during lockdown periods when their own practices were not operational.Personal factors, such as COVID-related suffering within their own families also motivated providers.Seeing the immediate effect of their effort was also a motivator for providers to continue their engagement.

"
Step One gave me a platform where I got authenticated information… I was able to help my COVIDaffected family members… provide them with medical assistance because I was linked with the chain.Thirdly, …the feeling of satisfaction… it was around 12 at night… we were able to shift a very serious patient to ICU within 25 min.So that feeling of satisfaction of saving a life, you cannot achieve it by any other means.That feeling is priceless." [FGD Participant #3].Some medical students from institutions that had partnered with StepOne reported that their participation on StepOne was mandated by their affiliated professional organizations.

Barriers
To identify the barriers to engagement, providers were asked about personal and environmental factors that inhibited their participation on the platform.Some practitioner's engagement was inhibited by the overwhelming nature of the work.During the pandemic's peak, many providers reported receiving distressing calls and requests from patients in need of urgent medical intervention or assistance beyond the scope of StepOne.This accentuated a feeling of helplessness and inhibited the involvement of some providers.One provider stated: "That was a reason for me to not take a lot of calls, because I would get really distressed by those words.…. the calls where we cannot help in any way, don't give those calls to us, because then we feel so helpless." [Subject #8].
As the number of COVID-19 cases fell, lack of new cases led providers to reduce their engagement with StepOne.Many stated their willingness to be involved if there were a similar initiative in the future.Respondents also cited regular work engagements as limiting their available time to volunteer as the pandemic abated.

Suggestions for improvement
Providers suggested that it would be more rewarding for them to close the consultation loop through followup consultations.This is especially relevant to the Ste-pOne model, where patients and providers are randomly matched through the algorithm at each interaction, not allowing for patient-provider continuity throughout the process.

"..if there was a follow-up button, I would like to follow up with this person tomorrow. So maybe that ticket gets autogenerated to you.. " [Subject #8].
Prescribing drugs with complex names was difficult, necessitating several providers to text patients drug names using their personal telephones.Providers suggested a chat feature for prescriptions over text, thereby reducing the need to share their personal contact details.Several providers recommended an initial administrative screening to reduce their burden by ensuring completeness and accuracy of patient information, screening irrelevant calls, and identify priority cases.One provider suggested instituting protocols to verify doctors' credentials and providing certificates of authenticity to the patients to build patients' trust.
Medical students suggested allowing for the transfer of patients to a specialist in instances where they felt under-confident in prescribing guidance, treatment, or medication through the platform.Some volunteers also suggested video calls as a feature to allay the lack of inperson interaction.

Financial and non-financial incentives Financial incentives
Providers reported varied and conflicting perceptions on receiving financial incentives to participate on StepOne.Many believed that financial incentives would help maintain the regular engagement of providers.

"… it becomes like a part-time job for healthcare providers … so like per ticket [patient] if you pay,
[and] you give them some sort of monetary incentive.So, whenever they are free, they'll come back… So, that will 100% motivate them to stay on the platform.Take it from me, a lot of people will join the platform." [Subject #12].
However, other providers stated that financial incentives contradict the motivation of volunteering and service.

"I think it would do more harm than good to start monetizing it…, you have to talk to a patient and they are not customers… (if ) you'll get a reward by talking to say 30 patients a day, I'd rather talk properly to three patients than you know, hurry and rush it up with 30 patients. " [Subject #14].
Providers also varied in their suggestions of structuring financial incentives.Suggestions included incentives per patient consulted, an hourly versus a flat rate, or incentivizing by disease type where a long-term provider-patient match is established for chronic disease cases.A few providers recommended a token charge incurred by patients for treatment compliance to increase the value of their medical advice.

Non-financial incentives
Providers favorably viewed a range of non-pecuniary rewards, including stories of providers helping people, gift hampers, statements of appreciation, and certificates of recognition.In the absence of financial incentives, non-financial incentives were expected by almost all.Recognition and appreciation for their time and tireless effort during a pandemic, were the most frequently highlighted non-financial incentives.
"….the doctor on the other side needs to know that their efforts are being recognised.It's not always about money, a small gesture is enough to make the doctor happy." [FGD Participant #3].
When providers were asked about continuing to volunteer post-pandemic to increase access to healthcare, one provider recommended a hybrid model of volunteers and providers who are paid a small monetary payment.The tension between financial and non-financial incentives is highlighted by the following quote: "So even though it doesn't sound good, financial incentives definitely will draw people.But again, there are pros and cons….welose that aura that we get on StepOne when it becomes a commercial plat-form…..There's no simple solution." [FGD Participant #1].

Positives of telemedicine
Providers stated that telemedicine could increase access to healthcare and reduce the costs of seeking healthcare, especially for the poor.

"In many places, we can't reach the people… We are very poor in our healthcare system… this type of platform is helpful to go to the remote area. Or many people are incapacitated. …. And many people cannot make time to go at a regular particular time to visit a doctor, wait… I feel this type of platform are required and they're definitely going to help. " [Subject #5].
Through StepOne providers grew their own professional skills, including increased confidence when talking to patients, especially for current medical students, and building online consultation skills for providers generally.One provider stated that telemedicine allowed providers who were no longer practicing for personal reasons, such as lack of childcare, the flexibility to practice from home.

Negatives of telemedicine
Unpleasant interactions contributed to the negative experience for providers.Instances of such unpleasant interactions, including a lack of appreciation, were reported when patient expectations were not met during consultations or when patients received multiple follow-up from different providers.One provider reported: "….when my own patient comes, I know them, I can talk to them… But here…the government has sent some patient who enlisted as COVID care.And some of them are very erratic… very arrogant… some patients are rude…Some people used to shout at us." [Subject #5].
Providers stated that the inability to interact with patients offline limited telemedicine's effectiveness, and that it can only be used as a supplementary tool.

Volunteer telemedicine after COVID-19 Post-COVID-19 engagement
Provider engagement on StepOne reduced as COVID-19 waned and with the increase in other work demands.Providers highlighted the benefits of telemedicine beyond COVID-19, including for preventative services and non-communicable diseases such as diabetes and hypertension.

"…for diabetes and other (diseases like) hypertension, non-communicable diseases, creating awareness on preventing those diseases, and how it can help other individuals (through telemedicine). " [Subject #13].
A few providers mentioned leveraging telemedicine to address health issues that carry societal stigma, such as leprosy, HIV/AIDS and mental health, emergency consultations, and to increase access to healthcare in rural and remote areas.One provider suggested connecting primary doctors in remote areas to specialists elsewhere to increase healthcare access.

"… if this kind of teleconsultation was used…especially for rural patients, with video as well … then I'm sure it would help a lot of people, especially poor people, and it would save a lot of money for them for traveling purposes or other unnecessary things. And only those who require hospital admission can travel. " [Subject #11].
Some novel suggestions included utilizing StepOne as a webinar platform post-COVID to promote awareness, and scheduling talks on topics, such as lifestyle modification after diabetes, where audience members can raise questions and seek clarifications.Some providers highlighted the challenges of incorporating telemedicine into post-pandemic regular healthcare provision.One provider stressed that the pandemic-induced reliance on telemedicine may not continue after COVID-19 and patients may return for in-person consultations.Two other providers expressed skepticism about adopting telemedicine, including concerns about medical legal issues.
To recruit post-COVID-19, providers stressed leveraging provider networks on social media platforms such as WhatsApp and Telegram, where providers connect to support and exchange knowledge.

Discussion
In this study, we interviewed health practitioners from StepOne, a volunteer telemedicine network, to deepen our understanding of online medical volunteerism.The increase in volunteering during emergencies, including medical emergencies like COVID-19 is a known phenomenon [30][31][32][33][34][35].The challenges posed by COVID-19 forced an adaptation of the traditional model of in-person volunteering, aided by already existing technology.One study found that social media networks were crucial in the mobilization of providers online [36].Similar to our results where the lack of direct contact was a concern, a study of online volunteers who tutored children one-on-one during the pandemic reported concerns regarding establishing a personal connection online [37].This highlights a potential limitation of virtual volunteering and its effectiveness in settings where a one-to-one rapport is important.
While COVID-19 propelled the growth of medical volunteerism through telemedicine, not enough is understood about how telemedicine volunteerism can be leveraged within a country to plug regional shortages of health practitioners during emergencies.A study of physician volunteerism in international telemedicine reported physicians being concerned with patient care challenges but motivated by methods to increase connection with patients.This parallels the interviewed providers' suggestion of follow-up calls to ensure patient-provider continuity [24].Another study reported that the medical volunteers felt unprepared for the pandemic and were the target of stigmatization and discrimination [26], echoing our interviewed providers negative experiences.A study on burnout syndrome found that volunteers in emergency care reported higher levels of emotional exhaustion and depersonalization, and lower levels of personal accomplishment than other medical volunteers staff [38].This raises the question of provider burnout, the sustainability of medical volunteering during an emergency, and what organizational measures can be leveraged to protect medical volunteers during such times.
Our findings illustrate a tension between the mission-driven volunteer work and financial incentives for providers.While many stated that financial incentives would sustain engagement over time, some providers felt that monetary rewards ran counter to the spirit and motivation of volunteering.This tracks with the literature, where some studies illustrate a positive effect of financial incentives on motivating volunteers [39,40], while others demonstrate a neutral or negative effect on volunteer motivation.A study on physician volunteerism in international telemedicine reported that remuneration did not increase the likelihood of volunteering.Financial rewards were also found to crowd out image motivation for prosocial behavior [41] and undermine intrinsic motivation, with volunteers working less when financially rewarded in one study [42].Most literature on incentives to motivate health workers focuses on community health workers with mixed results found on the effectiveness of financial and non-financial incentives [43][44][45][46][47].Our study builds on this by suggesting that non-financial incentives may sustain the motivation of volunteer providers.While the non-financial rewards stated were largely appreciation and recognition centered, the providers did state that opportunities to network and build skills positively impacted their engagement with the telemedicine network.
Overall, we find that providers are hopeful about the potential of telemedicine to provide both preventative and specialized care while increasing access to healthcare for the rural and the marginalized.This is in keeping with the impact of telemedicine found in developed nations [2,[48][49][50].However, there is a lack of research on the impact of telemedicine and its ability to increase access to healthcare in LMICs.
This study has several limitations.First, only 18 providers were interviewed.However, despite the small sample, thematic saturation was achieved.Second, the study has a national dimension, covering only one Indian telemedicine operator.It would be desirable to compare the findings with other telemedicine networks beyond India.Finally, since the interviewed providers selfselected into the study, the results cannot be generalized to the entire provider population of StepOne or even the whole provider population of India.
Despite these limitations, the study has several strengths and makes a strong contribution to the growing literature on virtual medical volunteering.There is a scarcity of work on telemedicine-facilitated medical volunteerism, an area of relevance both for present and future pandemics.As climate change is predicted to exacerbate the occurrences of pandemics [51], understanding how existing technology and resources can be leveraged to meet healthcare demand surges is critical.While previous research has explored volunteer motivation, to our knowledge, this is the first study that explores providers volunteer telemedicine experiences in their own country.Additionally, while other studies have focused on a single provider type, this study covers a range of health practitioners, ranging from medical students to specialists across the public and the private health sectors.Finally, this study highlights several areas of future research and organizational challenges to be addressed in order to fully leverage the potential of volunteerism over telemedicine, providing a direction to further the field of study.

Conclusion
The use of telemedicine has been crucial in the response to the COVID-19 pandemic.Such interventions are important channels in LMICs for improving access to healthcare and reducing treatment costs.In addition to insights into the motivations and barriers to telemedicine use, studying providers' experiences identifies areas of improvement towards ensuring the sustainable use of volunteer telemedicine to address healthcare needs in LMICs.It also highlights the need for careful consideration of pecuniary and non-pecuniary benefits for providers.In addition, the application of such a platform to other healthcare domains, such as treatment for non-communicable diseases or improving access for less-served communities, provides ample opportunity for future research.This will help in the identification of incentives for medical volunteers, cost of adoption and training needs among health practitioners, and also test the sustainability of any such large-scale interventions.

Appendix 1: Matrix display of quotations
Table displays the key demographic characteristics of respondents.These include the type of interview, respondents age, specialization in medical practice, years of experience, and the region of their physical location